The intent of the “Traumatic Brain Injury (TBI) Documentation Template” is to provide information from the referring provider to the consulting specialists, for a number of consults relevant to the management of TBI patients. This documentation template is used in conjunction with another one used for the TBI screening itself, which also supplies information to the consulting specialists. This template supplies information specific to the consult request process, and is completed automatically, only when the referring provider has indicated intention to consult relevant specialties in the “TBI Screening Documentation Template”.
Artifact Creation and Usage
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Structured code that is interpretable by a computer (includes data elements, value sets, logic)
- Target User
- Primary Care
- Clinical Focus
- Adult patients with suspected Traumatic Brain Injury
- Clinical Venue
- Patient Age Group
- Adult patients
- Patient Gender
- Workflow Task
- Request Neurology Consultation
- Derived From
- Neurology: Traumatic Brain Injury Screening Clinical Content White Paper
- Associated Resource
- Neurology: Traumatic Brain Injury (TBI) Documentation Template Conceptual Structure Document
- Associated Resource
- Neurology: Traumatic Brain Injury (TBI) Documentation Template KNART Validation Report
See attached resource files for additional details. Department of Veterans Affairs, Veterans Health Administration, Office of Informatics and Information Governance, Clinical Decision Support (CDS) Content and Health Level 7 (HL7)-Compliant Knowledge Artifacts (KNARTs) Eye Care Clinical Content White Paper, VA118-16-D-1008, Task Order VA-118-16-F-1008-0007, June, 2018.
- Mild Traumatic Brain Injury Rehabilitation Toolkit. Army Medical Department Center and School ( AMEDDC&S ), U.S. Army Health Readiness Center of Excellence ( HRCoE ) website. Accessed August 28, 2017
- Management of Concussion-mild Traumatic Brain Injury (mTBI), Version 2.0 – 2016. VA/DoD Clinical Practice Guidelines website. Management of Concussion/mTBI Working Group. Published February 2016